Provider Demographics
NPI:1629036207
Name:BAUER, TRACY K (PA)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:K
Last Name:BAUER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:TRACY
Other - Middle Name:ELAINE
Other - Last Name:KRAWCZYK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:425 ESSJAY RD STE 170
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-5782
Mailing Address - Country:US
Mailing Address - Phone:716-630-1219
Mailing Address - Fax:
Practice Address - Street 1:295 ESSJAY RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-8216
Practice Address - Country:US
Practice Address - Phone:716-630-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2021-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0057091363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0400501003374OtherFIDELIS
NY11563494OtherCAQH
NY177013BJOtherPREFERRED CARE
NY000570180003OtherBCBS
NYP001890577OtherMEDICARE RAILROAD
NY9513165OtherIHA
NY000570180003OtherBCBS
NY177013BJOtherPREFERRED CARE